Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low‐Risk Women?

Abstract: Background: Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low‐risk women planning to give birth in these settings under the care of midwives. Methods: Data for a cohort of low‐risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. Results: Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66–5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05–1.87; RR: 1.78, 95% CI: 1.31–2.42) than women planning to give birth in a primary unit. Conclusions: Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth. (BIRTH 38:2 June 2011)     

Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial

Objective

infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia. If the infant's blood glucose is low and the mother is unable to breast feed/provide sufficient expressed breast milk, infants are often given formula. Some hospitals encourage women with diabetes to express breast milk before birth. However, there is limited evidence for this practice, including its impact on labour and birth, e.g. causing premature birth may be a concern. A pilot study was undertaken to establish the feasibility of conducting an adequately powered randomised controlled trial to evaluate this practice.

Design

consecutive eligible women with pre-existing or gestational diabetes (requiring insulin), planning to breast feed and attending the study hospital were offered participation. Inclusion criteria: 34-36 weeks of gestation; singleton pregnancy; cephalic presentation; and able to speak, read and write in English. Exclusion criteria: history of spontaneous preterm birth, antepartum haemorrhage, placenta praevia and suspected fetal compromise. Women were encouraged to express colostrum twice a day from 36 weeks of gestation, and advised how to store the colostrum, which was frozen for their infant's use after birth. They were asked to keep a diary documenting their expressing. Data: demographic questionnaire, telephone interview at six and 12 weeks postpartum and medical record data.

Setting

a public, tertiary, women's hospital in Melbourne, Australia.

Participants

43 women with diabetes in pregnancy (requiring insulin).

Findings

cardiotocographs were undertaken after the first expressing episode and none of the infants showed any sign of fetal compromise. Forty per cent of infants received formula in the 24 hours postpartum. The proportion of infants receiving any breast milk at six weeks was 90%, and this decreased to 75% at 12 weeks. No women showed evidence of hypoglycaemia post expressing. The intervention was positively received by most women; 95% said that they would express antenatally again if the practice proved to be beneficial. The amount of colostrum varied according to the number of expressions, the length of time in the study and the time spent expressing, with a median of 14 days expressing and 39.6 ml of colostrum obtained.

Key conclusions

the small number of women in this pilot was not an adequate number to examine safety or efficacy, but this study does provide evidence that it would be feasible and desirable to conduct a randomised controlled trial of antenatal milk expressing for women with diabetes requiring insulin in pregnancy.

Implications for practice

it is important that this widespread practice undergoes rigorous evaluation to assess both efficacy and safety. Until such evidence is available, the authors suggest that the routine encouragement of antenatal milk expressing in women with diabetes in pregnancy should cease.     

Redesigning postnatal care: exploring the views and experiences of midwives

Objective: women have consistently rated postnatal care less favourably than other episodes of maternity care. Midwives have also reported concerns with postnatal care, with challenges related to workloads, busy environments and lack of staff. Given these concerns, a regional hospital in Victoria, Australia redesigned its postnatal care provision. The changes included cessation of routine postnatal observations and the use of clinical pathways for women who gave birth vaginally; promotion of rest through minimal disturbances before 9 am; discouraging the use of the call bell system except in emergency situations; introduction of ‘one-to-one’ time with women; and promotion of normalcy and independence. This paper examines midwives' views of the changes and their impressions of the effects of the changes on women and their infants.